Positive changes in the nutrition and
health of the Cuban population have taken place in the last three
decades. The strategies developed for their attainment have been
mainly in the public health sector. Changes in health indicators
closely linked to the nutrition status of the community in the
last 20 years indicate that the population's standard of living
has risen. However, there has been a tendency to both an absolute
and a relative increase in the prevalence of and mortality from
chronic non-communicable diseases and in their associated risk
factors. On the other hand, moderate or severe protein-energy
deficiency is not common, but iron deficiency is still a problem,
especially in small children and pregnant women. Several
strategies and actions currently are in progress for promoting a
positive change in food habits and lifestyle.

Changes in Cuban nutrition and
health

The nutrition and health of the Cuban
population have shown dramatic improvements in the last three
decades. Living standards have been substantially raised by the
elimination of illiteracy and unemployment, the permanent
availability of education and health services, and the guarantee
of basic goods for life regardless of personal income. The mean
daily per capita intake of energy increased from 2,552 kcal (10.6
MJ) in 1965 to 2,899 kcal (12.1 MJ) in 1988, and that of protein
from 66.4 g to 77.4 g in the same period. The proportion of
protein from animal sources represents 46.4% of the total,
whereas 25 years ago it was 43.5%. Fat represents 24.1 % of total
energy consumed [1]. All these data are recorded through the food
balance sheets methodology proposed by FAO. This includes the
analysis of food wastage, which yields the estimated amount of
food available for human consumption [1].

More than 3 million portions are served daily
in canteens in schools, universities, day-care centres,
factories, military units, and other locations, free or at very
low prices [2]. This represents an important amount, taking into
account the population of Cuba (10,603,200 in 1990). The mean
monthly salary has increased 26% in the last five years, whereas
the cost of living, especially the cost of basic foods, has
changed very little in the last ten years.

The strategies in public health rested
originally on the creation of the National Health System, with
the development of a preventive and curative network at the
primary level of health care which ensured health services for
all the population. A new model of health service, based on the
family doctor, was initiated in 1984, and in 1990 it covered more
than half the population.

The health actions that have made a major
contribution to the improvement of the nutrition status of the
population have included:

the national programme of immunizations
(1960),

the acute diarrhoeal disease control
programme (1962),

the development of prenatal care, with
emphasis on controlling the nutrition status of pregnant
women, the establishment of special out-patient care
services for those at risk, and the creation of
surveillance homes,

the establishment of special out-patient
care services for undernourished infants and small
children and the creation of nutritional recovery homes,

the National Food and Nutrition
Surveillance System (1977),

the National Mother and Child Care
Programme (1980),

the programme for sanitary education.

Other measures not directly related to health
were undertaken simultaneously, including the elimination of
illiteracy, increasing the education level of the population,
improvement of water supplies and sanitation, increasing family
income, and electrification of small urban and rural settlements.

Indicators of nutrition status

The results of these strategies, which were
developed in a step-wise fashion in response to the growing needs
of the people, can be appreciated through various indirect and
direct indicators of nutrition status.

Indirect indicator

Changes that have taken place mainly in the
last 20 years are reflected in some health indicators closely
linked to the nutrition status of the community. They reveal
health standards in Cuba that resemble those of most developed
countries.

Life expectancy for males has increased from
66.8 years in 1969 to 72.2 years in 1989, and for females from
70.3 to 75.8 years in the same period of time. Eighty per cent of
deaths occur in subjects above 50 years of age and more than 62%
in those above age 65. The survival of children at 5 years was
98.7% in 1990 compared to 94.6% in 1969 [3].

Figure 1 shows the changes in selected
nationwide indicators from 1969 to 1990: the infant mortality
rate decreased from 46.7 to 10.7 per 1,000 live births,
under-five proportional mortality from 23.6% to 3.5%, the
proportion of deaths due to infectious diseases from 9.5% to
1.5%, and the mortality rate for children 1-4 years old from 1.8
to 0.7 per 1,000. Diarrhoeal diseases are not among the first ten
causes of death for all ages, and are only the fourth cause of
death among infants (0.5 per 1,000 live births). In the same
period, the low-birth-weight (<2,500 g) rate decreased from
10.3 to 7.3 per 100 live births.

Conversely, a tendency to increase was shown by
mortality rates related to unhealthy food or living habits (fig.
2). In the same period, the mortality rate due to cardiovascular
diseases (the first cause of death in Cuba) increased from 149.1
to 200.3 per 100,000 people; that due to malignant diseases (the
second cause of death) increased from 96.6 to 128.5;
cerebro-vascular diseases (the third cause of death) remained
unchanged at 66.2; and diabetes mellitus (the sixth cause of
death in 1990) rose from 12.6 to 21.4.

Table 1 shows the five main causes of death for
each age group in Cuba in 1990 and their rates. Heart diseases
are first among subjects 50 years old or over and third among
those 15-49 years old [3]. Figure 3 shows the components of
mortality by cardiovascular diseases, revealing an accelerating
increase in deaths due to ischaemic heart disease.

All this has a great impact on children's
health, since it emphasizes the need to prevent at early ages
diseases of adults that have their origin in childhood; thus,
strategies have changed as health figures of the population have.

TABLE 1. Mortality rates for the five main causes of death
within each age group. Cuba, 1990.

The National Food and Nutrition Surveillance
System (SISVAN) is one of the sources of knowledge required to
ensure the adequate nutrition of the community. Nutrition
surveillance implies monitoring and control of the nutrition
status of the population in order to make decisions that can lead
to its improvement.

SISVAN was begun in Cuba in 1977 [4] with the
support of the United Nations Children's Fund (UNICEF) and the
Pan American Health Organization for three years. By the
beginning of the 1980s its coverage was nationwide. This
achievement was possible because of the already existent
sectorized structure of the official organizations that attend to
agriculture and cattle production, trade, social feeding, public
health, etc. related to each of the three organizational levels
of the state: nation, province, and municipality [5]. Currently,
SISVAN has three components: surveillance of mother's and
children's nutrition, dietary surveillance in social feeding, and
surveillance of chemical and biological food contaminants.

The system started with surveillance of child
nutrition, making use of the primary health care network, which
rendered all parallel structures superfluous. It covers the whole
population under 5 years of age (885,300 in 1990), whose body
weights and heights are measured periodically at out-patient
centres established by the National Mother and Child Care
Programme. The indicator used is body weight for height, with
percentiles of the national figures [6] as the reference
standard. Children classified in the following four categories on
the basis of those values are singled out for attention:

possibly undernourished, those
with weight for height below the 3rd percentile,

thin, those between the 3rd and
9th percentiles,

overweight, those between the
90th and 96th percentiles,

possibly obese, those at or above
the 97th percentile.

Children between the 10th and 89th percentiles
are considered normal. For each of the four atypical groups, two
factors are considered: the frequency of initial diagnoses (new
cases), and the prevalence among the children under surveillance.

Atypical subjects detected at the primary
health care level participate in a special care programme at the
out-patient clinics with more thorough and specific follow-up. If
necessary, they are admitted to the hospital. The prevalence of
the four categories from 1984 to 1990 is shown in figures 4
(infants) and 5 (children 1-4 years old). A decreasing trend is
observed for all four categories, especially for children with
possible undernutrition, the prevalence of which is very low
compared to that reported by international organizations for
other developing countries [7]. The frequency of new cases has
also tended to decrease in all the categories. In 1990 the
reported figures for infants were I . I % possibly
undernourished, 4.1 % thin, 4.7% overweight, and 1.5% possibly
obese. For children 1-4 years old the figures were 0.2%, 0.5%,
0.7% and 0.4% respectively [3]

The following indicators are used for the
surveillance of the nutrition of pregnant women (186,658 births
in 1990, of which 99.8% took place in health care units):

low weight for height at the beginning of
pregnancy-women below the 10th percentile of the Cuban
reference values for adults [8] at their first visit to
the out-patient service. usually between the eighth and
twelfth week of pregnancy: Table 2 shows the percentages
of pregnant women at risk according to these three
indicators for the period 1984-1990.

insufficient weight gain during
pregnancy-those with a gain of less than 8 kg at the end
of the pregnancy;

anaemia at the third trimester of
pregnancy-those with a haemoglobin concentration below
110 g/L (11 g/dl) [9]

TABLE 2. Pregnant women at risk
according to three nutrition-surveillance indicators
(percentages)

Low initial weight/height

Insufficient weight gain

Anaemia at 3rd trimester

1984

10.3

6.9

13.8

1985

10.9

7.4

14.0

1986

9.2

6.5

13.1

1987

8.7

5.4

11.2

1988

7.9

5.3

11.1

1989

8.8

5.5

12.3

1990

8.7

5.5

11.4

Source: SISVAN, Ministry of Public
Health, Cuba 1990.

National child-growth studies

The first national child-growth study was
carried out in 1972. A total of 56,00 subjects, constituting a
representative sample of the Cuban population 0-19 years old,
were measured [10, 11]. A second study was carried out in 1982:
an equiprobabilistic sample of 29,759 subjects 0.01-19.9 years
old were examined to obtain a description of the characteristics
of their physical growth, neuromotor development, somatotype, and
functional capacity. The somatic growth data were compared with
those obtained in 1972 [12] The results of these comparisons
showed that in 1982 the subjects were heavier and taller for
their ages, especially at the 50th and 97th percentiles
(particularly those above 10 years of age), and were also heavier
for their height [12, 13]. The body dimensions of infants,
children, and adolescents from rural areas showed greater
increments than those from urban areas. Fatness indicators such
as skinfold and fat areas of the upper arm showed increments both
in males and in females. All this points to a positive secular
trend in 10 years, but also to a tendency to increased obesity in
the population.

The World Health Organization has proposed as a
goal to be reached by the year 2000 a group of indicators, among
which are three directly related to the nutrition status of the
population [14]: weight for age, height for age, and weight for
height. This goal proposes that 90% of the children of the member
countries of WHO should show results for those dimensions above
the mean or median minus two standard deviations of WHO reference
values [15] This goal was reached in Cuba almost two decades ago,
since the values of the 10th percentile of the Cuban 1972 sample
are higher than those proposed by WHO for the year 2000 [16]

TABLE 3. Elementary school children
(6-11 years old) and adolescents (12-18 years old) in SISVAN
weight-for-height risk categories. Cuba. 1986

Weight-for-height survey in elementary
school children and adolescents

In a study carried out in 1986 in a sample of
19,428 children from elementary schools (6-11 years old) and
11,450 from high schools (12-18 years old) [17], it was found
that the proportion of thin and possibly undernourished subjects
(according to the SISVAN criteria) was low, whereas the
proportion of overweight and obese subjects was higher among the
younger students (table 3).

These figures, together with the results of a
survey carried out at the National Institute of Endocrinology in
which the estimated prevalence of obesity (body mass index >
30 kg/m²) in subjects above 15 years of age was estimated at
21.8% [18], show that obesity starts to be important at school
age and is particularly significant in young adults.

Indicators of iron deficiency

Iron deficiency is the most common nutritional
deficiency in Cuba, though its degree and severity do not reach
those found in other developing countries. In 1973 haemoglobin
values below the WHO cut-off line for anaemia (110 g/L) were
reported in 45.2% of infants 6-12 months old in the city of
Havana [19]. In 1985 anaemia was observed in 33.9% of 484
children 6-23 months old attending day-care centres in Havana
province (excluding the capital city); in 78% of these the
anaemia was mild (haemoglobin between 100 and 109 g/L) [20] In
the same sample. 42% showed serum iron concentrations below 10.7
umol/L [20] Other studies carried out in several regions of the
country found that the proportion of children with haemoglobin
below 110 g/L ranged between 45% and 63% [21, 22].

Iron deficiency in pregnant women is also
important: in samples obtained in the city of Havana, 22% had
haemoglobin values below 110 g/L and 6% below 100 g/L; 35%
exhibited transferrin saturation figures below 15%. Conversely,
no folic-acid deficiency was found [23, 24]. As shown in table 1,
according to SISVAN, the national rate of anaemia in the third
trimester of gestation was 11.4 per 100 pregnant women in 1990.

Indicators of other specific nutrient
deficiencies

Besides iron deficiency, no other specific
nutrient deficiencies are significant enough to constitute health
problems in Cuba. In studies carried out in groups of
schoolchildren and adolescents and in pregnant and lactating
women, a relatively low proportion of subjects had serum vitamin
A classified as deficient (<10 g/dl) or low (10-19 ug/dl) [25,
26].

Relations between food habits and
nutrition and health

We can sum up the current nutrition and health
situation in Cuba as follows:

Severe protein-energy deficiency is not
common.

Iron deficiency affects an important
proportion of children and pregnant women.

The rate of low birth weight has been
reduced but requires additional attention.

Obesity, especially in schoolchildren,
adolescents, and young adults, is frequent and
increasing.

An increasing trend is observed in the
rates of deaths due to cardiovascular diseases, malignant
diseases, and diabetes mellitus, which contribute to more
than two-thirds of all deaths.

These conditions have a multifactoral origin,
food habits being among the most relevant factors. The increased
capacity to acquire food has not corresponded with a change in
food habits and hence in the quality of life.

Cuba has a higher per capita sugar consumption,
52.7 kg in 1988, than any other country in the world. Sugar
represents 19.7% of the total energy intake of the population
[1].

Fruits and fresh vegetables have a seasonal
distribution and are not available throughout the year. In
addition, people are not used to eating them in sufficient
quantities. Less than one-third of the fat consumed comes from
vegetable sources. Only a low proportion of the animal fat comes
from fish. A national survey carried out by the Cuban Research
Institute of Internal Demand, investigating people's proclivity
to change their current habits of food consumption, reported a
tendency to eat more fruits and vegetables as well as larger
quantities of fats and sugar. Twenty-three per cent of households
belonged to a class of consumers characterized by high intake of
energy-related foods (lard, butter, sugar, rice), and they
continue to increase the consumption of these items. The
principal characteristics of these families are low income, rural
origin, and low socio-economic status [27]

One common feature of food habits is an
unsatisfactory distribution of daily energy intake, with a major
proportion ingested at the end of the day. In one study healthy
adult men 20-50 years old were grouped into seven categories
according to their physical activity. Breakfast represented a
mean of only 4.4% of their total energy intake, whereas dinner
represented 42.6%; nearly one-fourth of the subjects received
more than half of their energy at the evening meal [28].

A low prevalence and duration of breast-feeding
and early introduction of solid foods characterizes
infant-feeding practices. In a cohort study of 4,272 infants from
birth to 7 months of age, 89.8% were breast-fed at 7 days. This
proportion dropped to 45.2% at 3 months, including not only those
who were exclusively breast-feeding but also those fed by breast
and bottle. In the first month of life, a significant proportion
of the infants received fruit juices (16.5%), fruit purees
(12.4%), mashed tubers (4.6%), cereals (1.8%), meat (2.0%), and
egg yolk (1.4%) [29]. The introduction of solid foods in the
first seven months was directly related to the maternal education
level [30]. Similar results have been found in more recent
reports [31-33].

Strategies for immediate action

Cuba has defined its strategies and actions to
preserve and improve the nutrition status of the population
through the National Food and Nutrition Programme, established in
1988 [34]. This programme includes four basic approaches:
socio-economic, educational, medical, and organizational. It is
systematic and multisectoral and is focused on improving the
health of the population through the creation of proper food
habits. It comprises quantitative and qualitative aspects of food
based on interventions in the planning of production, imports,
marketing, food elaboration and food distribution. All sectors of
the economy and services related to feeding the population are
included. Evaluations are made annually, and within one year of
its implementation, promising results had been obtained.

The main goals of the programme are as follows:

to develop a nationwide, multisectoral
campaign for better food habits:

decreasing sugar consumption to less
than 15% of total energy intake,

reducing total fat intake, and
increasing vegetable-oil consumption to at least 50%
of total fat intake,

increasing fish consumption.

increasing the availability of fresh
vegetables and fruits throughout the year;

to improve the National Food and Nutrition
Surveillance System:

including other indicators (arm
circumference) and groups of subjects under
surveillance (schoolchildren, adolescents),

developing software for dietary
evaluations;

to improve the Mother and Child Care Programme:

increasing the prevalence and duration
of breast-feeding,

reducing the low-birth-weight rate to
under 6 per 100 births,

developing food products for pregnant
women, infants, and small children (including the
fortification of foods with iron and vitamin C);

to improve the primary health care
network:

extending the new model of care by the
family doctor to all the population,

establishing detection and special
out-patient care for subjects at risk of obesity and
chronic degenerative diseases,

developing programmes for massive
physical activities in the community.

The goals for forthcoming years will focus on
modifying current conditions and promoting a more healthy
lifestyle of the people. Coordinating the activities of
agriculture and animal production, the food industry, domestic
and foreign trade, education and mass-diffusion media, public
health. and mass organizations in the framework of the National
Food and Nutrition Programme should make the goals achievable in
the near future.